Pulmonary embolism, right ventricular strain, and intracardiac thrombus-in-transit: Evaluation using comprehensive cardiothoracic computed tomography

A 67-year-old woman presented with symptoms of exertional chest discomfort and dyspnea that had been progressive over the past few days. Her initial evaluation was significant of a mildly elevated troponin-T level and T-wave inversion in leads V₁-V₂ on an electrocardiogram (ECG). Initial suspicion was for acute coronary syndrome. However, a transthoracic echocardiogram showed normal left ventricular systolic function, moderate right ventricular enlargement with moderate decrease in systolic function, possible left atrial mass or thrombus, and a possible right atrial mass or thrombus versus a prominent Chiari network. ECG-gated comprehensive cardiothoracic computed tomography (CT) with a 64-slice multidetector CT was done to assess for pulmonary embolism or acute coronary syndrome and to further evaluate the possible right and left atrial masses. This showed large bilateral pulmonary embolism, interatrial thrombus in transit through a patent foramen ovale, and minimal coronary atherosclerosis. Dynamic imaging showed right ventricular enlargement with severe systolic dysfunction. The patient underwent successful pulmonary thromboembolectomy, removal of intracardiac thrombus, and closure of patent foramen ovale.